FP center with endoscopy/birthing center

[wasatch]

I am a bit discouraged when I see how difficult it has become to actually be a family physician these days. I am one that loves to do procedures, but also likes to live in an a larger city (Seattle). I don't understand how we have become left out and told what we can and cannot do by specialists. I am referring to colonoscopies and obstetrics.

Why should I have to leave my wonderful city and practice in a rural area just to provide the usual and customary family practice that we have been doing for hundreds of years?

Anyway, I was wondering if anyone had built a private practice that had built in a room for endoscopy and also an area for deliveries? I don't want to work for a hospital or anyone else for that matter. Why not have this type of building and ONLY have family physicians allowed to work there. FP's that have their own patients at their practice can come and use the facilities as well.

Personally, I am not interested in Ob, but I would love to do colonoscopies daily w/o having to go to the hospital.

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[ajce9]

I am a bit discouraged when I see how difficult it has become to actually be a family physician these days. I am one that loves to do procedures, but also likes to live in an a larger city (Seattle). I don't understand how we have become left out and told what we can and cannot do by specialists. I am referring to colonoscopies and obstetrics.

Why should I have to leave my wonderful city and practice in a rural area just to provide the usual and customary family practice that we have been doing for hundreds of years?

Anyway, I was wondering if anyone had built a private practice that had built in a room for endoscopy and also an area for deliveries? I don't want to work for a hospital or anyone else for that matter. Why not have this type of building and ONLY have family physicians allowed to work there. FP's that have their own patients at their practice can come and use the facilities as well.

Personally, I am not interested in Ob, but I would love to do colonoscopies daily w/o having to go to the hospital.

If you can afford to open one and then market the place you can do it.

you can't just have a place to do deliveries. You have to have 24 hr nursing to follow the patient in the nursery. You will also need to have an on-call anesthesiologist in case of c-sections or other birth emergencies and to place epidurals. I suspect it would have to be JACHO certified.

Off course all of the above are reimbursable by insurance. Insurance companies don't care where the baby is born. It's the hospitals in this case that won't give your the priviledges you deserve.

So if you open your own (it will be very expensive) you are set to go as long as you can bring in the business.

Birthing centers have been around for a long time. Family Medicine oriented obstetrics actually shows better outcomes than many OB/GYN. Patients are more comfortable and prefer the setting.

Not sure how your malpractice would increase.

As far as colonoscopies go, you will be able to do those is you are fast and accurate. It takes a GI doc and average of about 15 to minutes to run the length of the colon. It takes them about 15 minutes to do an EGD.

If you can do one in about that time then your good to go.

Consider adding a physical therapy center and market it to orthopedics and FP/IM/Rheumatologist/Geriatricians/workmans comp/anyone else you can think of.

If you are going to have a building you may as well take full advantage of it.

Good Luck.

 

[wasatch]

Maybe I will lease out space at the Walmart, next to Mcdonalds and have all these services available while you shop for t-shirts and tires! All they need then is a basketball court/gym and church and I am good to go.

 

[sophiejane]

Why should I have to leave my wonderful city and practice in a rural area just to provide the usual and customary family practice that we have been doing for hundreds of years?

Because your wonderful city (and Seattle is wonderful--no argument there) is saturated with specialists. People would seriously laugh at an all-FP clinic with birthing rooms in the back and endoscopy up front.

I understand that we would like to have it all, but it's kind of ridiculous to think you can offer a service in a city already fully saturated with doctors who devoted their whole training to learning that service, and you had a couple of months in it, and are down the block, and think you can compete.

See my other posts, I'm a huge FM fan. Love procedures. Not going to happen in an urban area. How about we start thinking about where the actual need for these services is rather than whining about how we have to leave the city to do them?

What ever happened to service?

Ah what the hell. I can't wait to get out of the city. Y'all can fight over procedures all you want, after you fight traffic to get to them.

 

[wasatch]

excuse me!!! whine about my city......f/u

 

[ajce9]

Because your wonderful city (and Seattle is wonderful--no argument there) is saturated with specialists. People would seriously laugh at an all-FP clinic with birthing rooms in the back and endoscopy up front.

I understand that we would like to have it all, but it's kind of ridiculous to think you can offer a service in a city already fully saturated with doctors who devoted their whole training to learning that service, and you had a couple of months in it, and are down the block, and think you can compete.

See my other posts, I'm a huge FM fan. Love procedures. Not going to happen in an urban area. How about we start thinking about where the actual need for these services is rather than whining about how we have to leave the city to do them?

What ever happened to service?

Ah what the hell. I can't wait to get out of the city. Y'all can fight over procedures all you want, after you fight traffic to get to them.

How do you know he has only a couple of months of experience?

After finishing residency you are suppose to be able to deliver babies, period.
You can do a fellowship to get good at c-sections.

If you did a full time fp office in there, you can get your colonoscopy patients from there. I bet you could do at least one a day.

As fars as the birthing center goes, this is not a new idea. its been done before and done well. You can market it to all obs if you want.

 

[Frijolero]

Because your wonderful city (and Seattle is wonderful--no argument there) is saturated with specialists. People would seriously laugh at an all-FP clinic with birthing rooms in the back and endoscopy up front.

I understand that we would like to have it all, but it's kind of ridiculous to think you can offer a service in a city already fully saturated with doctors who devoted their whole training to learning that service, and you had a couple of months in it, and are down the block, and think you can compete.

See my other posts, I'm a huge FM fan. Love procedures. Not going to happen in an urban area. How about we start thinking about where the actual need for these services is rather than whining about how we have to leave the city to do them?

What ever happened to service?

Ah what the hell. I can't wait to get out of the city. Y'all can fight over procedures all you want, after you fight traffic to get to them.

What specialty are you speaking of that devotes their whole training to doing cscopes and EGD's? I wouldn't choose family if I didn't believe that I could compete. If I had the choice between going to the doc I already see and like versus getting referred out to a GI specialist or general surgeon I'm picking my FP. Honestly, it's not rocket science, and the convenience is worth the small edge the GI doc might have on my FP. Same thing for e/o small skin lesions and a multitude of other minor procedures. Perhaps you underestimate the convenience factor. Sure, if people start from scratch to find someone to do their cscope or other small procedure, they're gonna call a specialist. But most people end up referred from the FP, and I'm willing to bet most prefer to stay with a doc they already know and trust who can do the same things for them with far less hassle.

Additionally, I think FP's not unfrequently do a better job than specialists with certain conditions. I've seen more than a few cardiac patients that felt like hell and looked worse because their beta blockers were cranked through the roof to protect their heart. Don't underestimate how frustrating it can be to be bounced around between multiple physicians. Most patients would rather stay with a single doc who can manage most everything, including basic procedures, than deal with the hassle that a referral often becomes. That is why FM will continue to do well.

 

[deleted87716]

I think FP's not unfrequently do a better job than specialists with certain conditions. I've seen more than a few cardiac patients that felt like hell and looked worse because their beta blockers were cranked through the roof to protect their heart. Don't underestimate how frustrating it can be to be bounced around between multiple physicians. Most patients would rather stay with a single doc who can manage most everything, including basic procedures, than deal with the hassle that a referral often becomes. That is why FM will continue to do well.

I agree, although I don't think you necessarily have to be a procedure hound in order to serve your patients well in this regard.

 

[secretwave101]

Man, I've been trying to work this out also, and the hurdles just keep comin'. I especially wish I could do OB, but I've rammed my head against the wall regarding endoscopies. In short, nobody will teach them to me down here (OP's neck of the woods, actually, in Olympia). I guess the startup costs to scopes etc is pretty dramatic also. 50k or something like that.

As for OB, no matter how good you are, you NEED OB backup. Even if you do a fellowship and are good at sections, you need OB backup 24/7. This is where you get hamstrung by specialists. They won't back you. At least, not around here. I saw a whole FP group give up OB just because the main OB group here wouldn't back them. Not to mention that your malpractice costs rise so much that you REALLY need to do a lot of deliveries to cover your costs. It's something like 70 deliveries just to break even (depending on your insurance mix). Most FP's who actively do OB do around 50 or less. Not to mention the crummy hours.

The last thing to remember is that, especially with OB, you need to do it right out of training, or you get out of practice. It's very unlikely that you will be able to stop in the middle of practicing a few years after training to do a fellowship at 50k/year. So, you need to hit the ground doing most of what you want to do...over the years, you can cut back. So, you'll need HUGE upfront money on top of what you owe from school. This is one of the other big hurdles.

Finally, a good-sized FP clinic that shared the costs and the risks could probably pull it off, but I'd guess you'd need at least 4 and better to have 6 in the practice...which is a pretty big patient population. Your presence WILL make waves. I'd think you'd need to be ravenous for non-medicare patients.

If anyone can think their way through all that, I'm all ears.

 

[Noyac]

What specialty are you speaking of that devotes their whole training to doing cscopes and EGD's? I wouldn't choose family if I didn't believe that I could compete. If I had the choice between going to the doc I already see and like versus getting referred out to a GI specialist or general surgeon I'm picking my FP. Honestly, it's not rocket science, and the convenience is worth the small edge the GI doc might have on my FP. Same thing for e/o small skin lesions and a multitude of other minor procedures. Perhaps you underestimate the convenience factor. Sure, if people start from scratch to find someone to do their cscope or other small procedure, they're gonna call a specialist. But most people end up referred from the FP, and I'm willing to bet most prefer to stay with a doc they already know and trust who can do the same things for them with far less hassle.

Additionally, I think FP's not unfrequently do a better job than specialists with certain conditions. I've seen more than a few cardiac patients that felt like hell and looked worse because their beta blockers were cranked through the roof to protect their heart. Don't underestimate how frustrating it can be to be bounced around between multiple physicians. Most patients would rather stay with a single doc who can manage most everything, including basic procedures, than deal with the hassle that a referral often becomes. That is why FM will continue to do well.

Thats one way to look at it.

Not the most logical, IMHO.

I work with both specialists and FP's. Trust me there is a BIG difference.

If I need a colonoscopy or a delivery (my wife actually) I want someone that does a ton of them. Not some generalist that wants to maintain some continuum of care, pad their wallet, or whatever else. Thats why big cities have these specialists. Rural areas are limited in resources therefore they get by with what they have.

 

[deleted87716]

I work with both specialists and FP's. Trust me there is a BIG difference.

If I need a colonoscopy or a delivery (my wife actually) I want someone that does a ton of them.

Most FP's who perform colonoscopies and deliveries do a ton of them. That's the only way to make the economics work, anyway. One of my partners has done well over 600 vasectomies, more than many urologists.

We're not talking about sacrificing quality for convenience; they're not mutually exclusive.

 

[drlisa0318]

Thats one way to look at it.

Not the most logical, IMHO.

I work with both specialists and FP's. Trust me there is a BIG difference.

If I need a colonoscopy or a delivery (my wife actually) I want someone that does a ton of them. Not some generalist that wants to maintain some continuum of care, pad their wallet, or whatever else. Thats why big cities have these specialists. Rural areas are limited in resources therefore they get by with what they have.

Speaking from a patient perspective (since I'm still a lowly premed and won't be applying to med school till 2008), I would MUCH rather see my FP rather than be referred to a specialist, whenever possible.

 

[Noyac]

Speaking from a patient perspective (since I'm still a lowly premed and won't be applying to med school till 2008), I would MUCH rather see my FP rather than be referred to a specialist, whenever possible.

That will change. And if it doesn't, well then I can't help you.

Listen, I think FP is a great field but to say that you can do procedures better than the specialists as frijolero stated is absurd.

And KentW, I understand that many FP's do a ton of these procedures. Actually, the ones I have worked with do quite a few (deliveries that is) and I can tell you the worst cases I have been involved with are frequently with FP's. Their skills are fine in the routine but not up to par in the crisis. they can't do hysterectomies when necessary (ruptured uterus or uncontroled bleeding) and blood loss is frequently 25 - 50% greater. Put it this way, we have a long history of FP's doing L&D and currently have a busy L&D floor. We also have a strong OB dept. The trend here is to get rid of the FP's in OB for safety reasons. The experience just isn't there and that leds to a deficiency in care. It's just not feasible any longer.

I am not picking on FP, hell my best buddy in Med Sch is FP and was doing deliveries but has since stopped for these reasons, but to say you are better is just not true. Think about it.

 

[deleted87716]

I am not picking on FP, hell my best buddy in Med Sch is FP and was doing deliveries but has since stopped for these reasons, but to say you are better is just not true.

Let's be honest, childbirth is a natural event, and pretty uneventful most of the time...relatively untrained midwives are delivering babies at home, for gawd's sake. It's not rocket science.

If there's an anesthesiologist in the room during a delivery (with the exception of epidurals), something's wrong. You, my friend, don't hang out during normal deliveries. All you get to see is the bad stuff. But...that's why (IMO) FPs who deliver babies need OB backup. So do midwives.

I don't deliver, however, so I'm not really the best person to talk to about OB.

Edit: As far as the whole "FPs doing procedures better than specialists" business goes, I'd put my skills at the procedures I do up against any specialist any time. If I didn't think I was the best person for the job, I wouldn't do it.

 

[dentate_gyrus]

Let's be honest, childbirth is a natural event, and pretty uneventful most of the time...relatively untrained midwives are delivering babies at home, for gawd's sake. It's not rocket science.

It's natural, but it ain't uneventful enough. When one of your own kid's deliveries heads south you find out real fast why women still die doing this.

If you get yourself a nice practice of compliant empowered upper middle class ladies you may be set. If you got a less empowered, kinda poor, kinda of not yet an adult, kinda obese with some HTN, some GDM they won't manage or proteinuria/HELLP, and maybe a drug habit or tendency to not show up to appointments and you can garner some complicated pregnancies. They aren't always obvious either. And get this, they can still have their babies whenever that water breaks, and you can't just walk away without providing some kind of appropriate care. And if these babies don't pop out just sparkling and perfect Mom goes straight for that lawyer. The jury sees that precious isn't a genius/athlete and it is damn well someone's fault - unfortunately you're "her doctor". So pay up.

So given all this, how would you convince me as an "OB/GYN" to A) let you compete with me for patients? and B) assume your liability in the clutch?

I just don't get what's in it for me.

 

[deleted87716]

Most FPs aren't going to be doing high-risk OB. However, they are trained to handle routine delivery complications, such as shoulder dystocia. Many of them are trained in c-section, as well.

As for OB backup, this isn't a novel concept. CT surgery routinely backs up cardiology in the event of a coronary artery injury during PTCA, general surgery and urology routinely back up OB-gyn in the event of a bowel or bladder injury, etc.

Regarding the malpractice insurance issue, that'll be equally problematic whether you're an FP or an OB-gyn. Many gynecologists have given up OB for the same reasons that many FPs have given up delivering babies.

 

[ajce9]

Thats one way to look at it.

Not the most logical, IMHO.

I work with both specialists and FP's. Trust me there is a BIG difference.

If I need a colonoscopy or a delivery (my wife actually) I want someone that does a ton of them. Not some generalist that wants to maintain some continuum of care, pad their wallet, or whatever else. Thats why big cities have these specialists. Rural areas are limited in resources therefore they get by with what they have.

If you don't do a TON of them then you don't have the experience. But like kent said most FPs that do them do a TON of them. It is unfortunate that you feel that SOME generalist will do these procedures to just pad their wallet.

Your statements do not support research thats been done on the subject and demonstrate your ignorance on the topic.

Over the past 20 years there has been many studies done on this topic. In fact JAMA publishes a more recent study demonstrating the effectiveness of FP in medicine and how in countries where they are in the majority the delivery and quality of care is significantly better. In fact the most recent study done demonstrates that the US came in LAST in heathcare and spent the most out of every country. This is a country that is top heavy with specialist.

You really need to do more research before you come in here and insult a group of highly trained physicians.

OH, by the way, Family physicians are not Generalist.

 

[ajce9]

That will change. And if it doesn't, well then I can't help you.

Listen, I think FP is a great field but to say that you can do procedures better than the specialists as frijolero stated is absurd.

And KentW, I understand that many FP's do a ton of these procedures. Actually, the ones I have worked with do quite a few (deliveries that is) and I can tell you the worst cases I have been involved with are frequently with FP's. Their skills are fine in the routine but not up to par in the crisis. they can't do hysterectomies when necessary (ruptured uterus or uncontroled bleeding) and blood loss is frequently 25 - 50% greater. Put it this way, we have a long history of FP's doing L&D and currently have a busy L&D floor. We also have a strong OB dept. The trend here is to get rid of the FP's in OB for safety reasons. The experience just isn't there and that leds to a deficiency in care. It's just not feasible any longer.

I am not picking on FP, hell my best buddy in Med Sch is FP and was doing deliveries but has since stopped for these reasons, but to say you are better is just not true. Think about it.

Again you show your ignorance.

I don't know a any gastroenterologist that can surgicaly treat a ruptured colon if they perf it. They call the surgeon. But they are quick to complain when a surgeon starts doing colonoscopies.

The problem with FP is not that they can't do the procedures. The problem is that over the years they have given up their turf to the specialty trend which has damaged medicine in the United States.

No one is saying that FPs can do procedures better than a certain specialist. It may be true that a specific FP can do a better Job than a specific specialist. However, overall the studies show that the results are equiviacal.

There is always going to be a need for specialist in order to handle the very most difficult of cases. But for most cases the trained FP can do as well.

 

[Frijolero]

That will change. And if it doesn't, well then I can't help you.

Listen, I think FP is a great field but to say that you can do procedures better than the specialists as frijolero stated is absurd.

And KentW, I understand that many FP's do a ton of these procedures. Actually, the ones I have worked with do quite a few (deliveries that is) and I can tell you the worst cases I have been involved with are frequently with FP's. Their skills are fine in the routine but not up to par in the crisis. they can't do hysterectomies when necessary (ruptured uterus or uncontroled bleeding) and blood loss is frequently 25 - 50% greater. Put it this way, we have a long history of FP's doing L&D and currently have a busy L&D floor. We also have a strong OB dept. The trend here is to get rid of the FP's in OB for safety reasons. The experience just isn't there and that leds to a deficiency in care. It's just not feasible any longer.

I am not picking on FP, hell my best buddy in Med Sch is FP and was doing deliveries but has since stopped for these reasons, but to say you are better is just not true. Think about it.

Hey mister straw man, don't tweak my words around and then call it absurd. Perhaps you'd like to go back and reread my post, especially the part that says "Additionally, I think FP's not unfrequently do a better job than specialists with certain conditions."

I specifically referred to medical management, not procedures. Read the rest of the post for an example about cardiologists, which can be extended out to any of the other specialties that sometimes lose site of the big picture.

As to procedures, I specifically stated that specialists likely do have an edge over FP's. My point was that most patients, including myself, would accept that fact in exchange for the convenience of not going to another office.

 

[Noyac]

Hey mister straw man, don't tweak my words around and then call it absurd. Perhaps you'd like to go back and reread my post, especially the part that says "Additionally, I think FP's not unfrequently do a better job than specialists with certain conditions."

I specifically referred to medical management, not procedures. Read the rest of the post for an example about cardiologists, which can be extended out to any of the other specialties that sometimes lose site of the big picture.

As to procedures, I specifically stated that specialists likely do have an edge over FP's. My point was that most patients, including myself, would accept that fact in exchange for the convenience of not going to another office.

Ok, I thought we were talking about procedures. Wasn't that the topic of this thread? My bad.

As far as the name calling "straw man" this is supposed to be an intelligent debate. Lets keep it that way.

 

[Noyac]

Most FPs aren't going to be doing high-risk OB. However, they are trained to handle routine delivery complications, such as shoulder dystocia. Many of them are trained in c-section, as well.

As for OB backup, this isn't a novel concept.

What would you call high risk then?

TOLAC?

Pre-eclamptics?

Breech?

FP's do these.

And c/s is another problem that I was referring to in my post. Greater frequency with Fp's and midwives at my facility, maybe not yours. Blood loss is greater as well in FP c/s. Cases are 30minutes longer. Post-op bleeding is more frequent. And our OB's don't back up our FP's. You know why? I'll bet you can guess, risk.

 

[Noyac]

If you don't do a TON of them then you don't have the experience. But like kent said most FPs that do them do a TON of them. It is unfortunate that you feel that SOME generalist will do these procedures to just pad their wallet.

Your statements do not support research thats been done on the subject and demonstrate your ignorance on the topic.

Over the past 20 years there has been many studies done on this topic. In fact JAMA publishes a more recent study demonstrating the effectiveness of FP in medicine and how in countries where they are in the majority the delivery and quality of care is significantly better. In fact the most recent study done demonstrates that the US came in LAST in heathcare and spent the most out of every country. This is a country that is top heavy with specialist.

You really need to do more research before you come in here and insult a group of highly trained physicians.

OH, by the way, Family physicians are not Generalist.

Well you state that there are studies but you don't produce them. I'm sure you can so lets see them. And be sure they are relevant. There are reasons beyond outcomes that the US ranks below some third world countries in births and infant mortality, etc.

 

[Noyac]

I'll so you my ignorance.
You claim that the Us ranks LAST in healthcare. Well lets take infant mortality as an example. We rank 2nd to last among developed countries. You know why?
Until the 1990's the former USSR did not count as a live birth or as an infant death extremely premature infants (less than 1,000 g., less than 28 weeks gestational age, or less than 35 cm in length) that were born showing signs of life but failed to survive for at least 7 days. The exclusion of those premature infants from the numbers of live births would result in a lower infant mortality.

Some countries count frail or premature infants who die before the normal due date as miscarriages (spontaneous abortions) and those who die during or immediately after childbirth as stillborn. The demographer Ansley Coale found dubiously high ratios of reported stillbirths to infant deaths in Hong Kong and Japan in the first 24 hours after birth, a pattern that is consistent with the high recorded sex ratios at birth in those countries and suggests not only that many female infants who die in the first 24 hours are misreported as stillbirths rather than infant deaths but also that those countries do not follow WHO recommendations for the reporting of live births and infant deaths.

In Austria and Germany, fetal weight must be at least 500 grams (1 pound) to count as a live birth; in other parts of Europe, such as Switzerland, the fetus must be at least 30 centimeters (12 inches) long. In Belgium and France, births at less than 26 weeks of pregnancy are registered as lifeless. When you consider the disparate definitions of live births it is easy to see why the United States would not compare favorably--particularly when other countries are using definitions that lower their infant mortality rate. Due to the wildly varying definitions of what constitutes a live birth and reporting requirements, the Organization for Economic Cooperation and Development, which collects the European numbers, warns of head-to-head comparisons by country.

How to define live birth isn't the only factor inflating the US infant mortality rate. America is more racially and economically diverse than many other industrialized countries. African-American babies are twice as likely as white infants to be premature, to have a low birth weight, and to die at birth; teen pregnancies and obesity both disproportionately affect African-American women and also increase risk for premature births and low birth weights, factors which raise the infant mortality rate. Thus, African-Americans have higher infant mortality rates than the country as a whole while various other ethnic groups, including Chinese Americans, have lower than average rates.

Iceland uses the same standards as we do but has a population under 300,000 that is 94 percent homogeneous, a mixture of Norse and Celts. Finland has a population of 5.2 million people with foreigners comprising only 2 percent. Japan's population is estimated at around one-hundred and twenty-seven million with a small population of foreign workers; 99% of the nation speaks Japanese as a first language. And on the other hand we have America with a multi-racial, polyglot population of 300 million people, home to 31 ethnic groups with more than a million members. Estimates suggest that we have 12 million undocumented immigrants, many of whom are women that do not seek prenatal care until they show up at the hospital to give birth. We have more illegal immigrants in our country than the entire populations of Finland and Iceland combined.

Paradoxically, our excellence at treating neonates, abundance of medical resources, and expanding fertility treatment industry may work against us in the attempt to lower infant mortality rates. "The United States has more neonatologists and neonatal intensive care beds per person than Australia, Canada and the United Kingdom, but its newborn rate is higher than any of those countries.

All of this information is available to you. Do your research.

You say we are top heavy with specialist/ Well god forbid you or any of us ever have a 25 week premie. But if you or I did were would you want that child born? In any other place than the US? Not me.

 

[ajce9]

I'll so you my ignorance.
You claim that the Us ranks LAST in healthcare. Well lets take infant mortality as an example. We rank 2nd to last among developed countries. You know why?
Until the 1990's the former USSR did not count as a live birth or as an infant death extremely premature infants (less than 1,000 g., less than 28 weeks gestational age, or less than 35 cm in length) that were born showing signs of life but failed to survive for at least 7 days. The exclusion of those premature infants from the numbers of live births would result in a lower infant mortality.

Some countries count frail or premature infants who die before the normal due date as miscarriages (spontaneous abortions) and those who die during or immediately after childbirth as stillborn. The demographer Ansley Coale found dubiously high ratios of reported stillbirths to infant deaths in Hong Kong and Japan in the first 24 hours after birth, a pattern that is consistent with the high recorded sex ratios at birth in those countries and suggests not only that many female infants who die in the first 24 hours are misreported as stillbirths rather than infant deaths but also that those countries do not follow WHO recommendations for the reporting of live births and infant deaths.

In Austria and Germany, fetal weight must be at least 500 grams (1 pound) to count as a live birth; in other parts of Europe, such as Switzerland, the fetus must be at least 30 centimeters (12 inches) long. In Belgium and France, births at less than 26 weeks of pregnancy are registered as lifeless. When you consider the disparate definitions of live births it is easy to see why the United States would not compare favorably--particularly when other countries are using definitions that lower their infant mortality rate. Due to the wildly varying definitions of what constitutes a live birth and reporting requirements, the Organization for Economic Cooperation and Development, which collects the European numbers, warns of head-to-head comparisons by country.

How to define live birth isn't the only factor inflating the US infant mortality rate. America is more racially and economically diverse than many other industrialized countries. African-American babies are twice as likely as white infants to be premature, to have a low birth weight, and to die at birth; teen pregnancies and obesity both disproportionately affect African-American women and also increase risk for premature births and low birth weights, factors which raise the infant mortality rate. Thus, African-Americans have higher infant mortality rates than the country as a whole while various other ethnic groups, including Chinese Americans, have lower than average rates.

Iceland uses the same standards as we do but has a population under 300,000 that is 94 percent homogeneous, a mixture of Norse and Celts. Finland has a population of 5.2 million people with foreigners comprising only 2 percent. Japan's population is estimated at around one-hundred and twenty-seven million with a small population of foreign workers; 99% of the nation speaks Japanese as a first language. And on the other hand we have America with a multi-racial, polyglot population of 300 million people, home to 31 ethnic groups with more than a million members. Estimates suggest that we have 12 million undocumented immigrants, many of whom are women that do not seek prenatal care until they show up at the hospital to give birth. We have more illegal immigrants in our country than the entire populations of Finland and Iceland combined.

Paradoxically, our excellence at treating neonates, abundance of medical resources, and expanding fertility treatment industry may work against us in the attempt to lower infant mortality rates. "The United States has more neonatologists and neonatal intensive care beds per person than Australia, Canada and the United Kingdom, but its newborn rate is higher than any of those countries.

All of this information is available to you. Do your research.

You say we are top heavy with specialist/ Well god forbid you or any of us ever have a 25 week premie. But if you or I did were would you want that child born? In any other place than the US? Not me.

Actually I was refering to the overall level of healthcare in the US vs. other western countries.

Go to aafp.org the newest report is posted in article there.

 

[Frijolero]

Ok, I thought we were talking about procedures. Wasn't that the topic of this thread? My bad.

As far as the name calling "straw man" this is supposed to be an intelligent debate. Lets keep it that way.

Classic. I wasn't calling you a straw man, I was using a common phrase referring to your tweaking of my words and then calling them absurd. Like if I had said "mister jump-to-conclusions". Which reminds me of this:

"It's a "Jump to Conclusions Mat! You see, you have this mat, with different CONCLUSIONS written on it that you could JUMP TO!
"That is the worst idea I have ever heard."
"Yes, this is horrible, this idea."

 

[deleted87716]

our OB's don't back up our FP's.

Well, that's the real problem.

 

[Tn Family MD]

Here's to whoever uttered teh words literature and family physician and OB together. There are a few studies out there. here they are:

Entrez pubmed Results

Items 1 - 13 of 13

1: Fam Med. 2006 Feb;38(2):103-9.


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Cesarean delivery results in a family medicine residency using a specific training model.

Heider A, Neely B, Bell L.

Family Practice and Obstetrics of Monett, 815 N\. Lincoln/Suite G, Monett, MO 65708, USA\. [email protected]

BACKGROUND AND OBJECTIVES: This study describes and evaluates a teaching model for training family medicine residents to perform cesarean deliveries and determines whether family medicine residents can achieve adequate quality care in the procedure\. METHODS: The teaching model for cesarean deliveries involved direct instruction and supervision by an obstetrician\. We conducted a review of all cesarean deliveries performed over a 3-year period by family medicine residents\. The review analyzed associated medical conditions, cesarean section indications, cesarean rate, blood loss, postoperative complications, and fetal outcome\. We compared these data to published outcomes in obstetrical literature and local obstetricians' data\. RESULTS: Maternal outcomes of all 277 cases performed under the teaching model were similar to other published results\. The family medicine residency's cesarean section rate (19.1%) was less than the national cesarean section rate (27.6%) and the local obstetricians' rate (22.6%)\. CONCLUSIONS: The teaching model outlined provides family medicine residents with the knowledge and skill to perform cesarean deliveries with high-quality standards.

PMID: 16450231 [PubMed - indexed for MEDLINE]

2: J Fam Pract. 1996 Nov;43(5):455-60.


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Are rural family physicians comfortable performing cesarean sections?

Norris TE, Reese JW, Pirani MJ, Rosenblatt RA.

WAMI Rural Health Research Center, Department of Family Medicine, University of Washington, Seattle 98195-6340, USA.

BACKGROUND: Provision of obstetric care in the United States requires the capacity to perform cesarean sections\. It is unknown who actually performs these procedures in rural hospitals and whether nonobstetricians feel comfortable performing cesarean sections\. METHODS: We conducted a telephone survey of the 41 rural hospitals in Washington State, asking about the obstetric services offered and the composition and obstetrical practices of physician staff\. A supplementary questionnaire was sent to the 112 family physicians providing obstetric services in the subset of hospitals with 50 or fewer beds, asking whether they performed cesarean sections\. Eighty-six responded, for a response rate of 75%\. RESULTS: Thirty-one (75%) of the rural hospitals provide obstetric services; of the 31 hospitals, 19 (61%) had no obstetricians on staff\. In these hospitals the majority of physicians on staff both practice obstetrics and perform cesarean sections\. Family physicians performed the majority of cesarean sections in all but the eight largest rural hospitals; even in these large hospitals (mean annual deliveries, 785), family physicians performed 28% of the cesarean sections\. Most family physicians who performed cesarean sections felt very comfortable performing these operations\. There was a strong association between the number of cesarean sections performed in formal residency training settings and the family physician's comfort level\. CONCLUSIONS: Cesarean sections remain an important service in those rural hospitals providing obstetric services\. Most Washington State rural hospitals depend on family physicians for this operative intervention\. Physicians' comfort in doing cesarean sections appears to be closely related to prior formal training during residency\. This relationship suggests that training programs preparing future rural physicians need to ensure adequate training in this area for their residents.

Publication Types:

· Research Support, U.S. Gov't, P.H.S.


PMID: 8917144 [PubMed - indexed for MEDLINE]

3: J Fam Pract. 1996 Nov;43(5):449-53.


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Who ever heard of family physicians performing cesarean sections?

Deutchman M.

Publication Types:

· Editorial


PMID: 8917143 [PubMed - indexed for MEDLINE]

4: J Am Board Fam Pract. 1995 Nov-Dec;8(6):440-7.


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Comment in:

· J Am Board Fam Pract. 1995 Nov-Dec;8(6):494-6.

· J Am Board Fam Pract. 1996 Mar-Apr;9(2):152-3.


Perinatal outcomes: a comparison between family physicians and obstetricians.

Deutchman ME, Sills D, Connor PD.

Department of Family Medicine, University of Colorado, Denver 80220, USA.

BACKGROUND: This retrospective study compared obstetrician and family physician patient population demographics, obstetric outcomes, delivery methods, and medical risk factors\. METHODS: Obstetricians and family practice faculty and residents provided delivery services at an urban community hospital\. A retrospective case study of all deliveries by obstetrician-gynecologists and family physicians in a 20-month period was analyzed with descriptive statistics, chi-square analysis, logistic regression, and power analysis\. A modified risk score analysis was completed on all patients to assess comparability between the obstetrician and family physician patients\. RESULTS: Risk score analysis of the two patient populations demonstrated no difference in high-risk patients (P = 0.102)\. Family physicians' patients had a lower incidence of Cesarean section, use of forceps, diagnosis of cephalopelvic disproportion, and low-birth-weight babies\. They had a higher incidence of spontaneous vaginal delivery, vaginal birth after previous Cesarean section, and vacuum extraction use\. The overall Cesarean section rate for family physicians was 15.4 percent, compared with 26.5 percent for obstetricians\. CONCLUSIONS: These findings support the high-quality outcomes of perinatal care provided by family physicians\. They also provide evidence for training and privileging family physicians to perform their own Cesarean sections.

Publication Types:

· Comparative Study


PMID: 8585401 [PubMed - indexed for MEDLINE]

5: Can Fam Physician. 1995 Apr;41:617-24.


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Comment in:

· Can Fam Physician. 1995 Apr;41:546-8, 552-4.

· Can Fam Physician. 1995 Apr;41:548-9, 554-6.

· Can Fam Physician. 1995 Jul;41:1153, 1155.


Family practice obstetrics in a community hospital.

Radomsky NA.

Red Deer Regional Hospital Centre.

OBJECTIVE: To review obstetric care provided by family physicians and to determine why they transfer patients to obstetricians\. DESIGN: Retrospective chart review\. SETTING: Obstetrics department of a regional non-academic community hospital PATIENTS: Of 683 women booked with family physicians for obstetrical care, 601 were admitted by family physicians and 82 were transferred to obstetricians before admission\. MAIN OUTCOME MEASURES: Risk score, induction, augmentation, consultation, forceps delivery, cesarean section, episiotomy, epidural anaesthesia, narcotic analgesia, neonatal birth weight and Apgar scores, and maternal complications\. RESULTS: Family physicians' patients had good maternal and neonatal outcomes; spontaneous delivery rate was 82%; cesarean section rate was 9%\. Women transferred from family physicians to obstetricians before admission for delivery had a cesarean section rate of 63%\. CONCLUSIONS: Family physicians provided total obstetric care to most women in this community and transferred patients to obstetricians for expected reasons\. Community hospitals with family physicians highly involved in providing obstetric care are likely ideal institutions for training future family physicians.

Publication Types:

· Research Support, Non-U.S. Gov't


PMID: 7787492 [PubMed - indexed for MEDLINE]

6: J Fam Pract. 1995 Apr;40(4):345-51.


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Comment in:

· J Fam Pract. 1995 Apr;40(4):401-2.


Practice variations between family physicians and obstetricians in the management of low-risk pregnancies.

Hueston WJ, Applegate JA, Mansfield CJ, King DE, McClaflin RR.

Department of Family Medicine, University of Wisconsin-Madison School of Medicine, USA.

BACKGROUND\. Studies suggest that family physicians and other generalist physicians practice differently than specialists\. This study was performed to determine whether practice patterns and outcomes differ for women with low-risk pregnancies who obtain maternity care from family physicians as compared with those who are cared for by obstetricians\. METHODS\. A retrospective chart review was performed at five sites across the United States\. Women who presented for elective repeat cesarean section or who had any one of 14 high-risk conditions were excluded from the analysis\. The final sample analyzed included 4865 women\. Family physicians managed the labor of 2000 of these women, and obstetricians managed 2865\. RESULTS\. During intrapartum care, women managed by family physicians were less likely to have their labor induced (8.6% vs 10.4%, P = .03), receive oxytocin augmentation (14.9% vs 17.8%, P = .006), or receive epidural anesthesia (5.4% vs 17.0%, P < .001) as compared with those managed by obstetricians\. Delivery outcomes showed that patients of family physicians were less likely to have an episiotomy during vaginal delivery (53.7% vs 74.5%, P < .001) and a lower frequency of cesarean section deliveries (9.3% vs 16.0%, P < .001), especially for cephalopelvic disproportion\. When adjusted for potential confounders, rates for cesarean section and episiotomy for obstetricians were still significantly higher than those of family physicians\. For neonatal outcomes (low 1-minute Apgar score, neonatal intensive care unit admission, birth trauma, or neonatal infection), no significant differences were found between the care delivered by obstetricians and family physicians\. CONCLUSIONS\. Women obtaining maternity care from family physicians were less likely to receive epidural anesthesia during labor or an episiotomy after vaginal births, and had a lower rate of cesarean section delivery rates, primarily because of a decreased frequency in the diagnosis of cephalopelvic disproportion\. Differences between outcomes persisted after adjustment for potential confounders such as parity, previous cesarean delivery, and use of epidural anesthesia during labor\. No differences between the two physician groups with respect to neonatal outcomes were found.

Publication Types:

· Comparative Study

· Multicenter Study

· Research Support, U.S. Gov't, P.H.S.


PMID: 7699347 [PubMed - indexed for MEDLINE]

7: Fam Med. 1995 Mar;27(3):182-7.


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Differences in labor and delivery experience in family physician- and obstetrician-supervised teaching services.

Hueston WJ, Rudy M.

Department of Family Medicine, University of Wisconsin, Madison, USA.

BACKGROUND: Other studies have shown that family physicians' pregnancy management styles are different from obstetricians' styles\. This study examines whether these differences also exist in teaching services supervised by family physicians and obstetricians\. METHODS: A retrospective study was done of deliveries performed by residents at five teaching hospitals in five states\. A total of 4,558 women were admitted to teaching services supervised by either family physicians (n = 1,754) or obstetricians (n = 2,804)\. Medical records for women whose labor and delivery were supervised by family physicians and obstetricians were reviewed and compared for demographics, pregnancy history, delivery management, and outcome variables\. RESULTS: Women admitted to teaching services supervised by family physicians were more likely to be younger and have no insurance, compared with those on services supervised by obstetricians\. Even after adjustment for pregnancy risk, obstetrician-supervised teaching services had an increased incidence of preterm labor, more frequent use of epidural anesthesia, and higher episiotomy and cesarean section rates than family practice teaching services\. CONCLUSIONS: The demographic and clinical characteristics of family practice and obstetric teaching services differ\. Patients on the services supervised by family physicians were more representative of the maternity practice of practicing family physicians.

Publication Types:

· Comparative Study

· Research Support, U.S. Gov't, P.H.S.


PMID: 7774778 [PubMed - indexed for MEDLINE]

8: J Am Board Fam Pract. 1995 Mar-Apr;8(2):81-90.


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Comment in:

· J Am Board Fam Pract. 1995 Mar-Apr;8(2):163-5.


Outcomes of cesarean sections performed by family physicians and the training they received: a 15-year retrospective study.

Deutchman M, Connor P, Gobbo R, FitzSimmons R.

Department of Family Medicine, University of Tennessee, Memphis, USA.

BACKGROUND: Family physicians are the major or sole providers of Cesarean section services in many communities\. Approximately 2800 family physicians provide Cesarean section services in communities of all sizes across the country\. METHODS: The outcomes of all Cesarean sections performed at two rural hospitals during a 10- to 15-year period were examined and compared with standard quality-outcome criteria published in the medical literature\. Outcome criteria included rates of various surgical complications, use of blood transfusion, infant Apgar scores, and length of postoperative hospital stay\. Other descriptive data were examined including patient demographics, operating time, anesthesia type, and choice of incision\. Statistical analysis consisted of chi-squares, odds ratios, and stepwise multiple regression\. RESULTS: Five hundred sixty-three Cesarean sections were performed by 12 residency-trained family physicians, 68 by general practitioners, 70 by general surgeons, and 9 by obstetrician-gynecologists\. Family physicians met or surpassed the referenced standards in all measures examined\. The number of Cesarean sections each physician performed while in residency training was also examined\. The average number of in-training Cesarean sections was 46, ranging from 25 to 100\. CONCLUSIONS: The results of this study support the ability of family physicians to provide Cesarean section services based on a wide range of training backgrounds and variable numbers of procedures done in training.

Publication Types:

· Research Support, Non-U.S. Gov't


PMID: 7778493 [PubMed - indexed for MEDLINE]

9: Fam Pract Res J. 1992 Sep;12(3):255-62.


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Comment in:

· Fam Pract Res J. 1992 Sep;12(3):225-30.


Cesarean section rate: a comparison between family physicians and obstetricians.

Applegate JA, Walhout MF.

Michigan State University.

This retrospective study compared the cesarean section rates of family physicians and obstetricians for low-risk pregnancies\. The study populations (n = 492) were demographically similar\. The overall cesarean section rate for the study was 7.5%\. Chi-square analysis revealed a statistically significant higher rate of cesarean section for obstetricians compared to family physicians\. Obstetricians were overall three times more likely to deliver by cesarean section than were family physicians (11.3% compared to 3.8%)\. This pattern persisted for normal-length Stage I and Stage II labors\. Equal cesarean section rates were noted in prolonged labor patterns\. The rate of fetal distress, meconium, or other complications was equal between family physicians and obstetricians; equivalent fetal outcomes and Apgar scores were noted\. None of the studied patient factors explained the difference in cesarean section rates between family physicians and obstetricians.

Publication Types:

· Comparative Study


PMID: 1414429 [PubMed - indexed for MEDLINE]

10: Fam Pract Res J. 1992 Sep;12(3):245-53.


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Comment in:

· Fam Pract Res J. 1992 Sep;12(3):225-30.


Specialty differences in primary cesarean section rates in a rural hospital.

Hueston WJ.

Menifee Medical Center, Frenchburg, Kentucky 40322.

To evaluate if physician specialty is a factor in determining whether cesarean sections are performed, a retrospective review of all obstetrical records was performed at a rural hospital in northeastern Kentucky\. Review of 1522 patients who delivered between January 1, 1987, and June 30, 1989, showed that staff obstetricians had a 10.8% cesarean rate compared with 8.9% for family physicians\. Analysis of the diagnoses that led to cesarean delivery showed no difference between the specialties for cesarean sections performed for fetal distress, preeclampsia, or other high-risk problems, but obstetricians had an increased cesarean section rate for cephalopelvic disproportion (10.7% of all deliveries vs 6.3% for family physicians, P less than 0.001)\. These results suggest that physician specialty may influence cesarean section rates, although other factors could also contribute to these results.

Publication Types:

· Comparative Study


PMID: 1414428 [PubMed - indexed for MEDLINE]

11: J Am Board Fam Pract. 1989 Jan-Mar;2(1):30-3.


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Obstetric care in a rural family practice.

Allen W.

Obstetrical care in the United States is becoming more difficult for rural populations to obtain\. Fewer family physicians are providing obstetrical services\. This study is a report of one family physician's obstetric experience in a small rural town\. In a series of 67 obstetrical patients, 8 percent of the deliveries occurred outside of the hospital\. The rate of Cesarean section was 3 percent, significantly less than the greater than 20 percent national average\. There was 1 premature delivery, and no infant deaths\. These figures compare well with national averages and show the need for family physicians to provide obstetrical care in rural areas.

PMID: 2923017 [PubMed - indexed for MEDLINE]

12: J Fam Pract. 1988 Oct;27(4):377-84.


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Comment in:

· J Fam Pract. 1989 May;28(5):510.


Obstetric outcomes in a rural family practice: an eight-year experience.

Kriebel SH, Pitts JD.

Family Medical Center, Forks, Washington 98331.

There has been debate in some quarters of whether family physicians should do obstetrics and of whether rural hospitals should provide obstetric services\. Forks, Washington, is a remote logging town where family physicians and midlevel practitioners have been the sole providers of labor and delivery services\. Forks offers an opportunity to evaluate the quality of an isolated rural family practice obstetric service\. A retrospective audit of all labor and delivery patient charts at Forks Community Hospital from 1975 to 1983 was undertaken; 1,052 charts were abstracted with 36 factors of morbidity, mortality, and intervention examined\. The results, when compared with similar studies in the literature, provide evidence of good performance\. In addition, a relatively high-risk obstetric population was served with favorable outcomes\. Family physicians and rural hospitals can provide high-quality obstetrical services.

Publication Types:

· Comparative Study

· Research Support, Non-U.S. Gov't


PMID: 3171489 [PubMed - indexed for MEDLINE]

13: J Fam Pract. 1987 Feb;24(2):159-64.


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The quality of obstetric care in family practice: are family physicians as safe as obstetricians?

Mengel MB, Phillips WR.

A literature review on the quality of obstetric care in family practice was conducted to determine whether family physicians are as competent in providing obstetric care as obstetricians\. Three types of studies were reviewed: case series, historical cohorts, and population-based studies\. No conclusion on the quality of obstetric care in family practice can be drawn from the available studies because of research design limitations\. Available evidence suggests, however, that family physicians are as safe as obstetricians when delivering babies, particularly when they concentrate their efforts on providing personal prenatal care, refer high-risk pregnant women appropriately, and practice less technologically oriented care on women who deliver normal-weight babies\. In addition, no evidence emerged that family physicians provided significantly poorer obstetric care than obstetricians\. In fact, the results from population-based studies suggest that family physicians may be safer than obstetricians in delivering normal-weight infants because of their hypothesized less use of technological interventions in that low-risk group of patients\. Further studies, especially prospective randomized trials in which the outcomes are assessed in a blinded fashion and case mix is rigorously controlled, are needed to provide a definitive answer\. As practical, ethical, and economic constraints are likely to preclude such studies, the case-control design may provide a reasonable alternative.

Publication Types:

· Comparative Study

· Research Support, Non-U.S. Gov't


PMID: 3806027 [PubMed - indexed for MEDLINE]


Have fun reading all those!

 

[ajce9]

I believe it was NOYAC that was asking for the studies.

Thank you for furnishing those.